Abstract
INTRODUCTION: Distal posterior cerebral artery (PCA) aneurysms are rare and surgically challenging lesions. We conducted this systematic review and meta‐analysis to evaluate clinical presentations, management strategies, and outcomes across studies. METHOD: We performed a systematic review and meta‐analysis in accordance with PRISMA 2020 guidelines. PubMed and Scopus databases were searched for studies published between January 2000 and June 2025 reporting clinical outcomes of distal PCA aneurysms (P2‐P5). Eligible studies included original data on treatment modality and outcome. Data were extracted independently by two reviewers, and the risk of bias was assessed using ROBINS‐I. Pooled estimates for functional outcomes, complications, and mortality were calculated using a random‐effects model. RESULTS: In our pooled analysis of 433 patients with distal PCA aneurysms (74.4% P2, 12.7% P3), endovascular therapy (EVT) was the predominant approach (71.4%), achieving a significantly higher good functional outcome rate than microsurgery (91.8% vs. 79.8%, p=0.011) and lower mortality (4.4% vs. 10.5%, p<0.001). Coiling alone provided superior safety, with lower recurrence (6.8% vs. 19.2%) and mortality (5.6% vs. 16.2%) compared to stent‐assisted coiling (both p<0.001). Flow diversion yielded 85.8% good outcomes but carried a 14.6% stroke risk. Anatomically, P3 aneurysms had higher mortality than P2 (12.2% vs. 3.4%, p=0.003). Adults had better outcomes than pediatric patients (81% vs. 67.8%, p=0.003), while size did not significantly influence mortality or functional recovery. CONCLUSION: EVT, coiling in particular, resulted in better safety and efficacy for the majority of the distal lesions. Microsurgery should be reserved for anatomically challenging or EVT‐failed lesions. [Image: see text] [Image: see text]